Obtaining consent from families for organ donation is the most important element of a successful transplant programme. In a recent large study of donor and non-donor families, 57% of families were predisposed to donate, 17% were unsure, and 25% were not in favour.1 The challenge is to secure consent from those people who are predisposed to donate, convert a substantial proportion of those who are unsure, and convert a smaller proportion of those who are initially not in favour. In the right circumstances this approach can achieve an 80% consent rate.

In the linked systematic review (doi:10.1136/bmj.b991), Simpkin and colleagues identify modifiable factors that influence relatives’ decisions to allow organ donation. They conclude that modifying the process of requesting consent may be the best way to increase organ donation rates in the United Kingdom.2 In a review published in the BMJ earlier this year, Rithalia and colleagues assess the effect of presumed consent legislation on organ donation rates and review data on attitudes towards presumed consent. Although many European countries have opted for presumed consent legislation in an effort to increase organ donation, the review shows that this legislation alone is unlikely to explain the variation in organ donation rates between countries, and multiple factors are probably at play because countries do not always follow their legislation strictly.3

Most factors involved in the consent process and outcome are modifiable. We now know much more about why families donate and factors that can increase consent rates.1 4 Best practices to increase organ donation have been accomplished through the recent US Department of Health Human Services Organ Donation Breakthrough Collaborative—organ donation increased by a cumulative 22.5% from October 2003 to October 2006.5 6 7 …